Objective: To observe the impact of improving the compliance of ventilator bundle on morbidity of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients undergoing mechanical ventilation (MV) guided by context of Joint Commission International (JCI) settings, and to study the oral care efficacy of suction tube sponge brush.
Methods: A prospective study was conducted. The patients who needed MV admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Xiamen University from January 2013 to December 2016 were enrolled. In the context of JCI settings, necessary measurements were taken to enhance the compliance of ventilator bundle each year. In 2013, the preventive measures were set up and the education was strengthened. In 2014, the compliance of hand hygiene and bedside elevation was strengthened. In 2015, a control study was conducted to evaluate the effect between the traditional cotton dipped in chlorhexidine and the suction tube sponge brush rinsed with chlorhexidine on oral health impact parameters. The suction tube sponge brush rinsed with chlorhexidine oral care was introduced to improve compliance. In 2016, electronic bundle checklist for daily self-audits was conducted. The annually morbidity of VAP through the software of hospital and ICU was collected and calculated. The annual incidence of VAP was indicated by the VAP cases per 1 000 MV days. Based on the VAP incidence rate in 2013 as 1, the VAP incidence-rate ratio (IRR) of each year was calculated.
Results: During the study period, a total of 2 733 patients admitted to the ICU, including 1 403 patients undergoing MV. Ninety-four of the 1 403 patients with community-acquired pneumonia (CAP), aspiration pneumonia, back elevation ban, incomplete information, and withdrew from the study were excluded. 1 399 patients undergoing MV were enrolled in the final analysis, with total MV days of 11 012 days, and 94 patients occurred VAP. The annual incidence of VAP was progressively declined from 2013 to 2016, and the VAP cases per 1 000 MV days were 17.0, 10.0, 5.9, 3.5 cases, respectively. Based on the VAP incidence rate in 2013, the IRR of VAP from 2014 to 2016 was also progressively declined, which was 0.59 [95% confidence interval (95%CI) = 0.35-0.98], 0.35 (95%CI = 0.18-0.64), and 0.21 (95%CI = 0.09-0.41), with statistical significance (all P < 0.05). In 2013, ICU patients had the lowest rates of bedside elevation and hand hygiene compliance, which were 28.57% and 54.29%, respectively. Compared with 2013, by the implementation of two quality control circle (QCC) projects for bedside elevation and hand hygiene, the rates of bedside elevation and hand hygiene compliance were improved significantly in 2014, which were 82.35%, 91.18%, respectively (both P < 0.05). In 2015, the compliance of chlorhexidine oral care which was the worst performed in 2014 had been improved by the method of QCC, and the rate of the compliance was significantly higher than that in 2013 (87.10% vs. 62.86%, P < 0.05). Compared with 2013, bundle compliance was significantly increased in 2016, except for the sterile operation of the suction tube [daily wake and weaning: 95.00% vs. 71.43%, bedside elevation for over 30degree angle: 92.50% vs. 28.57%, hand hygiene: 97.50% vs. 54.29%, chlorhexidine mouth care once per 6-8 hours: 95.00% vs. 62.86%, turned back and posture drainage: 97.50% vs. 80.00%], the differences were statistically significant (all P < 0.05). The incidences of bad breath, dirt residue and plaque were significantly lower in the group of oral care by using suction tube sponge brush with chlorhexidine (30 cases) compared with the group of traditional cotton pad with chlorhexidine (30 cases; bad breath: 10.0% vs. 40.0% %, dirt residue: 16.7% vs. 70.0%, plaque: 3.3% vs. 30.0%, all P < 0.05). There was no significant difference in the incidence of oral ulcers between the oral brush group and the traditional group (10.0% vs. 30.0%, P > 0.05).
Conclusions: Ventilator bundle can effectively reduce the morbidity of VAP in the context of JCI settings, and the oral care by using suction tube sponge brush and chlorhexidine can effectively improve oral hygiene.